St. Mary’s Early Childhood Center & Preschool
216 Belmont Rd.
Grand Forks, ND 58201
701-775-7067
projectkidsandtots@gmail.com
Registration Requirements:
1. Complete Application
o Child Information
o Admission Forms (3 pages)
o Weekly Schedule & Tuition Agreement (2 pages)
o Service Contract
o Parent’s Statement on Health of Child
o Child Information Sheet from the ND Department of Human Services
o Field Trip Permission Form (Parents will be notified when a field trip will be
scheduled)
o Notify Now Contract Form (School Announcements such as unscheduled
closings, weather related announcements, etc.)
o Photo Permission Release Form
o Pre-Authorized Automated Debit Release Form (2 pages)
2. Provide Copy of Current Immunization Records
3. Provide Copy of Birth Certificate
4. $30 non-refundable Registration Fee (September 1st Registration Fee will be $40.00)
o This fee is due annually
St. Mary’s Early Childhood Center & Preschool
Weekly Schedule and Tuition Agreement
Child’s Name:___________________________________________________
Child’s Birthdate:________________________________________________
Please select type of care needed

Full-Day Care: Your child may attend at any time during our normal business hours
(7:15 a.m. – 6:00 p.m.).
M–F
M

T
W
Th
F
Part-Day Care: Your child may attend for up to 5 hours/day. These hours must be
scheduled in advance to ensure adequate staffing. Care extending beyond the scheduled
5 hours will be billed at the drop-in rate of $6/hour.
M–F
M
T
W
Th
F
Please list scheduled attendance hours:________________________________________
________________________________________________________________________
________________________________________________________________________
PRICING SHEET IS LOCATED IN LEFT SIDE POCKET OF PACKET
Page 1

After-school Care: Additional full/part day rates will apply for all school in-service days
and holidays
M–F
M
T
W
@$55/week
Th
F
@$12/day
Additional drop-in hours may be added, as space allows, at a rate of $6/hour.
Multiple Child Discount
10% discount on each additional each from the same family.
Tuition Agreement
I agree to enroll my child at St. Mary’s Early Childhood Center & Preschool for the indicated
schedule and agree to pay the corresponding daily/hourly tuition rate beginning
(date)________________________.
I understand that payment is due in advance of care and agree to pay the monthly tuition on or
before the first day of the month that care is provided.
Parent Signature_________________________________________ Date__________________
Parent Signature_________________________________________ Date__________________
Pages 2
St. Mary’s Early Childhood Center & Preschool
Admission Forms
Parent/Guardian Information
Mother/Guardian
Name:______________________________ Social Security # ___________________________
Home Address_________________________________________________________________
_____________________________________________________________________________
Home Phone:_____________________________
Cell Phone:__________________________
Place of Employment:________________________ Work Phone:_________________________
Address:______________________________________________________________________
Father/Guardian
Name:______________________________ Social Security # ___________________________
Home Address_________________________________________________________________
_____________________________________________________________________________
Home Phone:_____________________________
Cell Phone:__________________________
Place of Employment:________________________ Work Phone:_________________________
Address:______________________________________________________________________
In the event that only one parent has custody of this child, please state which parent. Note:
We must have a copy of a court ordered custody agreement on file to withhold a child from a
non-custodial parent.
Custody:______________________________________________________________________
Signature:____________________________________________ Date:____________________
Page 1
Admission Form (Cont.)
Child Information
Child’s Preferred Name___________________________________
Does your child have siblings? Yes
No
If yes, how many?______
What year do you anticipate your child will start kindergarten? ________
Does your child still take an afternoon nap? Yes
Has your child previously attended child care? Yes
No
No
How was the experience?_________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Are there any areas that you anticipate your child may have difficulty? _____________________
______________________________________________________________________________
______________________________________________________________________________
Does your child have any special interests or hobbies? __________________________________
______________________________________________________________________________
______________________________________________________________________________
What would you like your child to gain by attending St. Mary’s Project Kids & Tots?_________
______________________________________________________________________________
______________________________________________________________________________
Recognizing that every child is an individual, does your child have any special needs or medical
conditions/allergies that we should be aware of?
_____________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Does your child need help in any of the following areas? (circle all that apply)
Dressing
Undressing
Washing Hands
Toileting
Eating
OTHER: _____________________________________________________________________
_____________________________________________________________________
Admission Form (Cont.)
Discipline
Parent/Guardian Statement on Discipline
St. Mary’s Early Childhood Center & Preschool understands that, at times, some form of
discipline may be necessary for my child(ren). I, therefore, give my permission for St. Mary’s
Early Childhood & Preschool, from whom I am receiving services, to use a non-severe discipline
(please see parent handbook for guidance methods used). I have found the most effective
method of guidance with my child to be:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Authorization to Release Child
Unless otherwise authorized by you in writing, no one but you or your spouse may pick up
your child(ren) from St. Mary’s Early Childhood & Preschool. List below any others you
wish to authorize for this purpose:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Page 2
Admission Form (Cont.)
Emergency Information
In case of an emergency and parents cannot be reached, who should be contacted?
Name:________________________________________________________________________
Home Address:_________________________________________________________________
Relationship to child:_______________________________ Phone #______________________
If Medical Care is Necessary, Call:
Doctor Name:_____________________________________ Phone #______________________
Address_______________________________________________________________________
Hospital__________________________________________ Phone#______________________
Address_______________________________________________________________________
Please list any allergies, medications or medical concerns that we should be aware of:_____
______________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I hereby authorize St. Mary’s Early Childhood Center & Preschool to secure emergency
medical treatment for my child under the following conditions:
1. An emergency or unanticipated condition necessitates action for the
preservation of life or health of the child
2. Reasonable attempts to contact me have failed
Print Name:____________________________________________________________________
Signature:________________________________________ Date:________________________
Page 3
St. Mary’s Early Childhood Center & Preschool
Service Contract
By signing this contract, I/we are agreeing to the following:
1. I have received, read, understand and agree to accept the terms in the Parent Handbook as
a condition of enrollment.
2. I understand that to be enrolled, the child’s shot record and birth certificate must
accompany the application.
3. I understand that to be enrolled, the $30.00 registration fee must accompany the
application. This fee is non-refundable.
4. I agree to pay the monthly tuition on or before the first day of the week that care is
provided. In the event that the tuition is not paid on time, I/we agree to pay a $5/day late
fee (including weekends).
5. I agree to provide a written two week notice upon termination of care and agree to pay
for two weeks of care should we terminate without prior notice.
Parent Signature__________________________________________________Date__________
Parent Signature__________________________________________________Date__________
St. Mary’s Early Childhood Center & Preschool
(Field Trip Form to go on neighborhood walks and to the local park)
Child’s Name__________________________________________________________________
Address_______________________________________________________________________
Home #_______________________________________
Mother/Guardian Name:_____________ Work #_______________ Cell # _________________
Father/Guardian Name:_____________ Work # _______________ Cell # _________________
Two emergency contacts who may assume responsibility for your child if you cannot be reached:
Name________________________________________ Phone # _________________________
Name________________________________________ Phone # _________________________
My child has permission to leave St. Mary’s Project Kids & Tots (on foot) for the purpose of
attending field trips.
Parent Signature:_______________________________ Date: ___________________________
You will be notified in advance if transportation will be utilized for any field trips.
Please list any allergies or medical conditions:________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
I hereby authorize St. Mary’s Project Kids & Tots to secure emergency medical treatment
for my child under the following conditions:
1. An emergency or unanticipated condition necessitates action for the
preservation of life or health of the child
2. Reasonable attempts to contact me have failed
Print Name:____________________________________________________________________
Signature:________________________________________ Date:________________________
Notify Now Contact Form
St. Mary’s Project Kids and Tots will post weather related closures/delays and other important
messages on WDAZ. We typically follow the same winter storm schedule as the Grand Forks
Public School system. We will also be using the Notify Now system to send out mass text and email messages to let you know of our closings or delays.
Child(ren)’s Name(s):____________________________________________________________
Parent Names(s):________________________________________________________________
Cell #s:_______________________________________________________________________
E-mail:________________________________________________________________________
Product Permission Form
St. Mary’s Early Childhood Center & Preschool will
supply hand lotion, sunscreen, bug repellant and handsanitizer should a child run out of their own. (Please label
all personal supplies.). We will keep this put away to be
used as needed. I give permission for the following
products to be applied to my child
(name)______________________________:
We will notify you and fill in the brand name of the
products.
Lotion:________________________________________
Chap stick:_____________________________________
Sunscreen:______________________________________
Bug Repellant:__________________________________
Parent Signature:_________________Date:___________
Dear Families,
For purposes of advertisement as well as to provide valuable
information to prospective and incoming families, St. Mary’s
maintains a website at www.stmarysgfnd.com .We like to
occasionally update the site with photos that reflect our evolving
curriculum and environments.
Please complete the bottom portion of this form to let us know if
we may use your child’s image for this purpose. Please note: we
will never post your child’s name or any other identifying
markers with the photographs.
Photo Release Form
o Yes, I give permission for images of my child,________________
to be used for advertising purposes on the St. Mary’s Early
Childhood and Preschool website through St. Mary’s
Church.
o Yes, I give permission for my child’s photo’s to be used in
classroom newsletters and bulletin boards.
No, I do not give permission for images of my child,
___________________ to be used for advertising purposes on
the St. Mary’s Project Kids & Tots website.
Signed_______________________________________Date________________
Pre-authorized Debits Customer Authorization Form
St. Mary’s Project Kids is pleased to offer you a new way to make your preschool/daycare
payments using pre-authorized debits. Now you can have your payment made automatically
each week and you don’t have to change your present banking relationship to take advantage of
this service.



No check writing with associated charges
Control over funds is guaranteed (via Regulation E)
Easy to sign up and easy to cancel
To take advantage of pre-authorized debits, simply complete the form as follows:




Check whether your payment will be deducted from your checking or savings account
Fill in your name, financial institute and location and date
Attach a voided check for verification of all the financial institution information. If you are unable to
attach a voided check, please provide your account number.
Sign form
Pre-authorized debits are safe, convenient, and easy. To take advantage of this service, please
complete the following information and return it along with your application packet.
YOU MUST COMPLETE THE ATTACHED FORM AND SUPPLY A
VOIDED CHECK EVEN IF YOU DO NOT SIGN UP FOR AUTOMATED
DEBITS.
In the event that your account becomes more than 2 weeks delinquent, this form authorizes us to
automatically deduct the past due tuition as well as all associated late fees.
Page 1
Pre-authorized Debits Customer Authorization Form
Please print the following:
Name:________________________________________________________________________
Address:______________________________________________________________________
Financial Institution:_____________________________________________________________
Branch:_______________________________________________________________________
Address:______________________________________________________________________
Signature:______________________________________________ Date:__________________
Bank Routing Number (9 digits):___________________________________________________
Account Number:_______________________________________________________________
Please select one of the following options.
1.
I do not wish to sign-up for pre-authorized, automated debits at this time. However, in
the event that my tuition fees become delinquent by more than two weeks, I authorize St.
Mary’s Church and the financial institute listed above to make a one-time deduction from
my account in the total amount past due along with all associated late fees.
Signature:_________________________________________ Date:_________________
2. I authorize St. Mary’s Church and the financial institute listed above to initiate electronic
debit entries, and if necessary, credit entries and adjustments for any debit entries in error
to my
( ) checking account
( ) savings account
I understand this payment will be withdrawn weekly on Monday (if this falls on a
holiday, transaction will occur the following business day).
I authorize a weekly deduction in the amount of $_______
This authority will remain in effect until I have canceled it in writing.
Signature:__________________________________________ Date:________________